Download Report

ARTICLE COVER SHEET
LWW—TECHNIQUES
FLA, SF, LTE and Case Study & Review
Article : bth20106
Creator : ew91
Date : 2/28/2007
Time : 2:19
Article Title :
Number of Pages (including this page) : 8
Template Version : 1.6
01/06/07
Scripts:
1. sc_Extract_Xml
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand and Upper Extremity Surgery 11(2):1Y6, 2007
|
Ó 2007 Lippincott Williams & Wilkins, Philadelphia
T E C H N I Q U E
|
Treatment of Early Basal Joint Arthritis
Using a Combined Arthroscopic Debridement
and Metacarpal Osteotomy
Alejandro Badia, MD and Prakash Khanchandani, MS
Hand, Upper Extremity and Microsurgery
Miami Hand Center
Miami, FL
| ABSTRACT
Osteoarthritis of the thumb basal joint is a common and
disabling condition, and early stages of which are often
seen in middle-aged women. Arthroscopic assessment
of the first carpometacarpal joint allows easy identification and classification of joint pathology with minimal morbidity. This allows the condition to be managed
either arthroscopically or converted to an open procedure as indicated. Different procedures have been
described to treat different stages of this disease. The
senior author has recently described an arthroscopic
staging system to determine treatment for basal joint
osteoarthritis. We now present our surgical technique
and early clinical experience with arthroscopic synovectomy, debridement, and corrective osteotomy for
arthroscopic stage II of thumb basal joint arthritis.
Forty-three patients (38 women and 5 men) were
arthroscopically diagnosed as having stage II basal joint
osteoarthritis of the thumb between 1998 and 2001, and
they were the focus of the present study. In all the
patients, there was no improvement after a period of 6 to
12 weeks of conservative treatment. All the procedures
were performed by the senior author. The surgical
procedure included arthroscopic synovectomy, debridement, and occasional thermal capsulorraphy, followed
by an extension-abduction closing wedge osteotomy in
all the cases. A 0.045-in Kirschner wire provided
stability to the osteotomy. By performing an osteotomy
that redirects the axial loads in this joint, we have
obtained satisfactory results in terms of pain relief,
stability, and pinch strength. Arthroscopy allows us to
not only determine the optimum indication for this
osteotomy, but also to debride the joint and minimize
the inflammatory response. Hence, we recommend
arthroscopic synovectomy, debridement with or without
a thermal capsulorraphy, and a dorsoradial closing
Address correspondence and reprint requests to Alejandro Badia, MD,
Miami Hand Center, Suite 100, 8905 SW 87th Ave, Miami, FL 33176.
E-mail: alex@surgical.net.
wedge osteotomy for the treatment of arthroscopic stage
II of thumb carpometacarpal joint osteoarthritis.
Keywords: thumb, carpometacarpal, osteoarthritis,
arthroscopy, osteotomy
| HISTORICAL PERSPECTIVE
The trapeziometacarpal (TMC) joint displays an exclusive anatomic design that allows arc of motion in three
different planes to place the thumb for axial loads. For
this reason, it is not uncommon for this joint to develop
osteoarthritis even when other small joints in the
vicinity stay unchanged.1 It has been demonstrated that
there is a strong correlation between extreme basal joint
laxity, specifically volar ligament instability, and
evolvement of the early degenerative changes.1Y8 These
alterations are common causes of pain, weakness, and
adduction deformity.9 Different procedures have been
proposed for the treatment of first carpometacarpal
(CMC) joint arthritis.1,3Y5,9Y32 Clinical and radiographic
assessments have constituted the basic tools for evaluation of the first CMC joint during the last several
decades.1,5,29Y31 Eaton and Glickel5 proposed a staging
system for thumb CMC arthritis, which has been
extensively used not just to categorize the disease, but
also to provide a treatment rationale. Bettinger et al30
introduced the trapezial tilt as a parameter to predict
further progression of the disease. They found that in
advanced stages (Eaton III and IV), the trapezial tilt was
high (50- T 4-; normal, 42- T 4-). Barron et al1
concluded that there appeared to be no indication for
magnetic resonance imaging (MRI), tomography, or
ultrasonography in the routine evaluation of basal joint
disease. Despite the importance of a radiographic
classification to understand the progression of the
disease, our experience has showed us that there are
instances when it is very difficult to make an accurate
diagnosis of the disease stage, based solely on radiographic studies. Clinical symptoms are often much more
pronounced than plain radiographs would suggest.29
Volume 11, Issue 2
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
Badia and Khanchandani
T1
Recent advances in arthroscopic technology have
allowed complete examination of smaller joints
throughout the body with minimal morbidity.33 Moreover, arthroscopy has already been proved to be reliable
for direct evaluation of the first CMC joint.32 This
technique is often used initially for diagnostic purposes
and, once established, can be incorporated into our
treatment plan. Arthroscopy of the thumb basal joint
allows us to look within a joint that is commonly
affected by both traumatic and chronic conditions,
providing clear visualization of the articular surfaces
and assessment of ligamentous integrity, and hence
permitting confirmation of the preoperative radiographic staging in all the cases. The senior author recently
described an arthroscopic classification for thumb CMC
osteoarthritis29 (Table 1).
The benefits of basal joint arthroscopy are evident in
early stages of the disease. For instance, in arthroscopic
stage I, it is very common to have normal radiographic
studies in the presence of painful limitation of the
thumb. In our experience, we have found that this group
of patients displayed mild to moderate synovitis that
could benefit from a thorough joint debridement/
synovectomy, combined with thermal shrinkage of the
ligaments to enhance the stability if necessary. Tomaino24,25 concluded that Eaton stage I disease is a good
indication for thumb metacarpal extension osteotomy. A
more reliable indication might be when there is only
focal articular cartilage loss and the joint is, therefore,
worth preserving. First metacarpal osteotomy has been
advocated to modify the mechanical stress areas of the
joint.9,23Y29 Based on the arthroscopic changes found in
stage II, we support the fact that it may be feasible to
modify the joint by an osteotomy and preserve the
trapezium. Moreover, the metaphyseal osteotomy leads
to decompression and reactive hyperemia that may help
in arresting the progression of the arthritis.34,35 Menon
described a technique demonstrating arthroscopic debridement of the trapezial articular surface and interpoTABLE 1. Badia’s Arthroscopic Classification
Stage
I
II
III
2
Arthroscopic Changes
Intact articular cartilage; disruption of the dorsoradial
ligament and diffuse synovial hypertrophy; inconsistent attenuation of the anterior oblique ligament
Frank eburnation of the articular cartilage on the
ulnar third of the base of first metacarpal and central
third of the distal surface of trapezium; disruption of
the dorsoradial ligament and more intense synovial
hypertrophy; constant attenuation of the anterior
oblique ligament
Widespread full-thickness cartilage loss with or
without a peripheral rim on both the articular
surfaces; less severe synovitis; frayed volar ligaments
with laxity
sition of autogenous tendon, fascia lata, or Gore-Tex
patch into the CMC joint in patients with stage II and
III.31 The main goal of the present study is to present the
surgical technique and results of our arthroscopic stage
II patients treated with an arthroscopic basal joint
debridement with capsulorraphy and a closing wedge
extension-abduction metacarpal osteotomy.
| INDICATIONS AND
CONTRAINDICATIONS
Stage II arthroscopic CMC joint arthritis is our
indication for the extension abduction metacarpal
osteotomy coupled with a thorough arthroscopic synovectomy and capsulorraphy. The joint findings that we
have previously described for arthroscopic stage II of
the disease warrants a modification of the joint by
changing the load vector on both the articular surfaces
through an osteotomy. Arthroscopy not only allows
staging of the arthritis but the joint can also be
effectively debrided, and capsulorraphy can be done.
However, this procedure should be avoided in advanced
basal joint arthritis or when scaphotrapezial-trapezoid
joint is arthritic, wherein a more aggressive procedure is
warranted. Eaton stage I might be amenable to a simple
synovectomy/debridement, reserving the osteotomy for
more advanced arthroscopic findings. On the other
hand, if the arthroscopic evaluation depicts complete
articular cartilage loss, the next logical step is to
perform partial trapezium excision with tendon interposition arthroplasty.
| ARTHROSCOPIC AND
RADIOGRAPHIC CORRELATION
Arthroscopic stage I universally correlate well with that
of radiographic stage I. Arthroscopic stage II usually
corresponds to radiographic stage II changes, but some
radiographic stage I patients may display focal loss of
articular cartilage consistent with arthroscopic stage II.
Herein lays one of the great advantages of this
technology. Only the rare case demonstrates less
cartilage wear than expected on the plain radiograph.
Consequently, radiographic stage III rarely is considered
arthroscopic stage II, but that does greatly influence and
diversify the treatment options. More advanced radiograph findings will usually reveal widespread cartilage
loss when arthroscopy is performed. Hence, later stages
are not necessarily a panacea as related to the use of
arthroscopy.
Surgical Technique
The procedure was performed under wrist block regional
anesthesia with tourniquet control. A single Chinese
finger trap was used on the thumb with 5 to 8 lb of
Techniques in Hand and Upper Extremity Surgery
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Combined Arthroscopic Debridement and Metacarpal Osteotomy
F1
F2
AQ1
longitudinal traction. The arm was held down with wide
tape around the tourniquet securing it to the hand table to
serve as countertraction. A shoulder holder, rather than a
traction tower, was used to facilitate fluoroscopic
intervention more easily. The Trapeziometacarpal joint
was detected by palpation. Joint distension was achieved
by injecting 1 to 3 mL of normal saline (Fig. 1). It is
important to distally direct the needle approximately 20
degrees to clear the dorsal flare of the metacarpal base
and enter the joint capsule. This course should be
reproduced upon entering with arthroscopic sleeve/
trocar assembly to minimize iatrogenic cartilage injury.
Fluid distention is important to facilitate this. The
incision for the 1-R (radial) portal, used for proper
assessment of the dorsoradial ligament, posterior
oblique ligament, and ulnar collateral ligament, was
placed just volar to the abductor pollicis longus tendon.
The incision for the 1-U (ulnar) portal, for better
evaluation of the anterior oblique ligament and ulnar
collateral ligament, was made just ulnar to the extensor
pollicis brevis tendon. A short-barrel, 1.9-mm, 30degree inclination arthroscope was used for complete
visualization of the CMC joint surfaces, capsule, and
ligaments, and then appropriate management was done,
as dictated by the stage of the arthritis detected (Fig.
2A). A full-radius mechanical shaver with suction was
used in all the cases, particularly for initial debridement
and visualization. Most of the cases were augmented
with radiofrequency ablation to perform a thorough
synovectomy and radiofrequency was also used to
perform chondroplasty in the cases with focal articular
cartilage wear or fibrillation. Chondroplasty refers to the
FIGURE 2. A, Carpometacarpal arthroscopy using ulnar
portal. B, Arthroscopic appearance of the joint showing
denuded cartilage and synovitis.
FIGURE 1. Insufflation of the TMJ joint after palpation.
debridement of the fibrillated cartilage to improve
vascularity of the cartilage and enhance the growth of
fibrocartilage. Ligamentous laxity and capsular attenuation were treated with thermal capsulorraphy using a
radiofrequency shrinkage probe. We were careful to
avoid thermal necrosis; hence, a striping technique was
used to tighten the capsule of the lax joints. The striping
technique refers to thermal shrinkage performed in
longitudinal stripes on the lax capsule, so as to leave
vascular zones between the stripes; hence, thermal
necrosis is prevented. Arthroscopic stage I disease was
characterized by synovitis without any cartilage wear,
wherein a synovectomy coupled with thermal capsulorraphy as described was performed.
Volume 11, Issue 2
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
Badia and Khanchandani
Arthroscopic stage II patients were characterized by
focal wear of the articular surface (Fig. 2B) that
required a joint modifying procedure, to alter the vector
forces across the joint. After synovectomy, debridement,
and occasional loose body removal, the joint was
reassessed to determine the extent of instability and
capsular attenuation. A shrinkage capsulorraphy was
performed in many of the cases, with chondroplasty
done to anneal the cartilage borders. The arthroscope
was then removed, and the ulnar portal extended distally
to expose the metacarpal base. Mini Hohmann retractors
were placed around the base allowing good access for
the oscillating saw (Fig. 3A). A dorsoradial closing
wedge osteotomy was then performed to place the thumb
in a more extended and abducted position (Fig. 3B and
C), which minimized the tendency of subluxation and
changed the contact points of worn articular cartilage.
This wedge of bone is usually 3 mm wide dorsally and
should also be wider on the radial side. This places the
thumb in the requisite dorsal and radially abducted
position. The osteotomy was fixed by a single oblique
0.045-inch Kirschner wire placed across the first CMC
joint in a reduced position (Fig. 4A and B). This not
only allowed for healing of the osteotomy in the desired
position but also corrected the metacarpal subluxation,
so often seen in this stage (Fig. 5A and B). As the
metaphysis heals, the volar capsule also tightens
minimizing the chance of recurrent subluxation. A
thumb spica cast was given for protection, and the wire
FIGURE 3. A, Preparation for the osteotomy of metacarpal metaphysis. B, Dorsoradial metacarpal osteotomy
performed. C, Closure of the metacarpal osteotomy.
4
FIGURE 4. A, Retrograde fixation of the metacarpal
osteotomy by Kirschner wire. B, Centralizing Kirschner
wire fixation of the metacarpal osteotomy.
Techniques in Hand and Upper Extremity Surgery
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
F3
F4
F5
Combined Arthroscopic Debridement and Metacarpal Osteotomy
FIGURE 5. A, Preoperative radiograph showing subluxation of the metacarpal. B, Postoperative radiograph showing wellreduced joint surfaces fixed with a Kirschner wire. C, Healed osteotomy of the metacarpal after Kirschner wire removal.
was removed at approximately 4 to 5 postoperative
weeks. After the wire removal, the patient is subjected
to an intense rehabilitation protocol for about 4 to 6
weeks to gain maximum motion and strength.
| COMPLICATIONS
In the present series, one of the patients developed
constant pain later owing to the progression of osteoarthritis after the procedure. She did not respond to steroid
injections and physical therapy. Eventually, she had to
undergo an arthroscopic assisted hemitrapezectomy,
with a good result. The second complication encountered in our series was complex regional pain syndrome
(type I) in one patient, who developed it after the pin
removal. This patient was managed with continuous
physical therapy, stellate brachial plexus blockades, and
neurontin.
metacarpal combined with synovectomy and capsulorraphy for the arthroscopic stage II patients. By preserving the joint, we have ‘‘burned no bridges,^ and a more
aggressive procedure, either arthroscopic or open, can
be done in the future if symptoms warrant. Hence,
arthroscopic visualization allows for the least aggressive
procedure to be performed as dictated by the intraoperative findings. According to the arthroscopic classification proposed, we recommend arthroscopic
synovectomy and thermal capsulorraphy in patients
with stage I, whereas in patients with stage II disease,
we combine the synovectomy and capsulorraphy with
dorsoradial osteotomy of the first metacarpal.
| REFERENCES
1. Barron OA, Glickel SZ, Eaton RG. Basal joint arthritis of
the thumb. J Am Acad Orthop Surg. 2000;8:314Y323.
| SUMMARY
As arthroscopy becomes validated as a technique, we
might see a day where less intra-articular injections are
given and more joint preservation, rather than palliation,
is sought. Arthroscopic assessment of the CMC joint
allows direct visualization of all components of the joint
including synovium, articular surfaces, ligaments, and
the joint capsule. Hence, it allows the evaluation and
staging of the joint pathology. Furthermore, the most
suitable intraoperative management decision can be
made based on this information. We recommend closing
wedge extension-abduction osteotomy of the first
2. Freedman DM, Eaton RG, Glickel SZ. Long-term results
of volar ligament reconstruction for symptomatic basal
joint laxity. J Hand Surg [Am]. 2000;25:297Y304.
3. Eaton RG, Littler JW. Ligament reconstruction for the
painful thumb carpometacarpal joint. J Bone Joint Surg.
1973;55A:1655Y1666.
4. Eaton RG, Lane LB, Littler JW, et al. Ligament reconstruction for the painful thumb carpometacarpal joint: a
long-term assessment. J Hand Surg [Am]. 1984;9:692Y699.
5. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis.
Staging as a rationale for treatment. Hand Clin. 1987;3:
455Y471.
Volume 11, Issue 2
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
5
Badia and Khanchandani
6. Kuczynski K. Carpometacarpal joint of the human thumb.
J Anat. 1974;118:119Y126.
7. Pellegrini VD Jr. Osteoarthritis of the trapeziometacarpal
joint: the pathophysiology of articular cartilage degeneration. I. Anatomy and pathology of the aging joint. J Hand
Surg [Am]. 1991;16:967Y974.
8. Pellegrini VD Jr. Osteoarthritis of the trapeziometacarpal
joint: the pathophysiology of articular cartilage degeneration. II. Articular wear patterns in the osteoarthritic joint.
J Hand Surg [Am]. 1991;16:975Y982.
9. Wilson JN, Bossley CJ. Osteotomy in the treatment of
osteoarthritis of the first carpometacarpal joint. J Bone
Joint Surg. 1983;65B:179Y181.
10. Burton RI, Pellegrini VD Jr. Surgical management of basal
joint arthritis of the thumb: part II. Ligament reconstruction
with tendon interposition arthroplasty. J Hand Surg [Am].
1986;11:324Y332.
20. Klimo GF, Verma RB, Baratz ME. The treatment of
trapeziometacarpal arthritis with arthrodesis. Hand Clin.
2001;17:261Y270.
21. Fulton DB, Stern PJ. Trapeziometacarpal arthrodesis in
primary osteoarthritis: a minimum two-year follow-up
study. J Hand Surg [Am]. 2001;26:109Y114.
22. Lisanti M, Rosati M, Spagnolli G, et al. Trapeziometacarpal joint arthrodesis for osteoarthritis. Results of power
staple fixation. J Hand Surg [Br]. 1997;22:576Y579.
23. Wilson JN. Basal osteotomy of the first metacarpal in the
treatment of arthritis of the carpometacarpal of the thumb.
Br J Surg. 1973;60:854Y858.
24. Tomaino MM. Treatment of Eaton stage I trapeziometacarpal disease. Ligament reconstruction or thumb metacarpal extension osteotomy? Hand Clin. 2001;17:197Y205.
25. Tomaino MM. Treatment of Eaton stage I trapeziometacarpal disease with thumb metacarpal extension osteotomy. J Hand Surg [Am]. 2000;25:1100Y1106.
11. Eaton RG, Glickel SZ, Littler JW. Tendon interposition
arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J Hand Surg [Am]. 1985;10:
645Y654.
26. Hobby JL, Lyall HA, Meggitt BF. First metacarpal
osteotomy for trapeziometacarpal osteoarthritis. J Bone
Joint Surg. 1998;80B:508Y512.
12. Barron OA, Eaton RG. Save the trapezium: double
interposition arthroplasty for the treatment of stage IV
disease of the basal joint. J Hand Surg [Am]. 1998;23:
196Y204.
27. Holmberg J, Lundborg G. Osteotomy of the first
metacarpal for osteoarthrosis of the basal joints of the
thumb. Scand J Plast Reconstr Surg Hand Surg. 1996;30:
67Y70.
13. Swigart CR, Eaton RG, Glickel SZ. Splinting in the
treatment of arthritis of the first carpometacarpal joint.
J Hand Surg [Am]. 1999;24:86Y91.
28. Molitor PJ, Emery RJ, Meggitt BF. First metacarpal
osteotomy for carpo-metacarpal osteoarthritis. J Hand
Surg [Br]. 1991;16:424Y427.
14. Varley GW, Calvey J, Hunter JB, et al. Excision of the
trapezium for osteoarthritis at the base of the thumb.
J Bone Joint Surg. 1994;76B:964Y968.
29. Badia A. Trapeziometacarpal arthroscopy: a classification
and treatment algorithm. Hand Clin. 2006;22:153Y163.
15. Froimson AI. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop. 1970;70:191Y199.
16. Tomaino MM, Pellegrini VD Jr, Burton RI. Arthroplasty
of the basal joint of the thumb: long-term follow-up after
ligament reconstruction with tendon interposition. J Bone
Joint Surg. 1995;77A:346Y355.
17. Lins RE, Gelberman RH, McKeown L, et al. Basal joint
arthritis: trapeziectomy with ligament reconstruction and
tendon interposition arthroplasty. J Hand Surg [Am].
1996;21:202Y209.
30. Bettinger PC, Linscheid RL, Cooney WP III, et al. Trapezial
tilt: a radiographic correlation with advanced trapeziometacarpal arthritis. J Hand Surg [Am]. 2001;26:692Y697.
31. Menon J. Arthroscopic management of trapeziometacarpal
joint arthritis of the thumb. Arthroscopy. 1996;12:581Y587.
32. Berger RA. Technique for arthroscopic evaluation of the
first carpometacarpal joint. J Hand Surg [Am]. 1997;22:
1077Y1080.
33. Chen YC. Arthroscopy of the wrist and finger joints.
Orthop Clin North Am. 1979;10:723Y733.
18. Eaton RG. Replacement of the trapezium for arthritis of
the basal articulations: a new technique with stabilization
tenodesis. J Bone Joint Surg. 1979;61A:76Y82.
34. Arnoldi CC, Lempberg RK, Linderholm H. Immediate
effect of osteotomy on the intramedullary pressure of the
femoral head and neck in patients with degenerative
osteoarthritis. Acta Orthop Scand. 1975;42:357Y365.
19. Diao E. Trapezio-metacarpal arthritis. Trapezium excision
and ligament reconstruction not including the LRTI
arthroplasty. Hand Clin. 2001;17:223Y236.
35. Illarramendi AA, De Carli P. Radius decompression for
treatment of Kienbock disease. Tech Hand Up Extrem
Surg. 2003;7:110Y113.
6
Techniques in Hand and Upper Extremity Surgery
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
AUTHOR QUERY
AUTHOR PLEASE ANSWER QUERY
AQ1 0 Please check if the provided running title is okay.
END OF AUTHOR QUERY
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Techniques in Hand & Upper
Extremity Surgery
Author(s) Name____________________________________________________________
2005/2006 Author Reprint Rates
Title of Article______________________________________________________________
Article #__________________Publication Mo/Yr________________
In addition to using this form to order
reprints, it is to be used to calculate any
additional publication fees your article may
Payment must be received before reprints can be shipped. Payment is accepted in the form
of a check or credit card; purchase orders are accepted for orders billed to a U.S. address.
MC
incur. Publication fees include color
VISA Discover
American Express
separation charges and page charges. Prices
Account #_______________________________________________ Exp. Date__________
are subject to change without notice.
Name_____________________________________________________________________
Quantities over 500 copies---contact our
Address___________________________________________________________________
Healthcare Dept. at 410-528-4426. Outside
Dept/Rm___________________________________________________________________
the U.S. dial 4420-7981-0700.
City______________________________________
State________________
Zip/Postal Code________________Country ____________________________
Fax or mail your order to Lippincott
Telephone_____________________Signature____________________________
Williams & Wilkins, Author Reprints Dept,
Reprint Cost
Quantity of Reprints = ______________________
$__________
Covers (Optional)
$108.00 for the first 100 copies
$18.00 each add’l 100 copies
$___________
$___________
351 W. Camden St., Baltimore, MD 21201.
Fax: 410-528-4434
Rapid Ordering can be accessed at
http://www.lww.com/periodicals/authorreprints. A confirmation of your order will
be e-mailed to you.
For questions regarding reprints or
publication fees please e-mail us at
reprints@lww.com or contact us at 1-800341-2258.
Reprint Pricing:
Color Fees (If your article contains color figures, use Rapid Ordering.)
Publication Color Charge (You may have included color figures in your article.
The costs to publish those figures may be included on the
reprint invoice or they may be invoiced separately.)
$___________
Reprint Color Cost ($70.00/100 reprints)
$___________
Shipping
Add $5.00 per 100 reprints for orders shipping within
the U.S. and $20.00 per 100 reprints for orders
shipping outside the U.S.
$__________
Tax
U.S. and Canadian residents add the appropriate
tax, or submit a tax exempt form.
$__________
100 copies = $375.00
200 copies = $441.00
Shipping Information
Ship:___________copies to:
300 copies = $510.00
Name_____________________________________________________________________
400 copies = $585.00
500 copies = $654.00
Address___________________________________________________________________
Dept/Rm___________________________________________________________________
City______________________________________
State________________
Zip/Postal Code________________Country ____________________________
Phone #___________________________________________________________________
Lippincott Williams & Wilkins, Baltimore, MD 21201
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.